C-JUN overexpressing CAR-T cells in acute myeloid leukemia: preclinical characterization and phase I trial

Chimeric antigen receptor (CAR) T cells show suboptimal efficacy in acute myeloid leukemia (AML). We find that CAR T cells exposed to myeloid leukemia show impaired activation and cytolytic function, accompanied by impaired antigen receptor downstream calcium, ZAP70, ERK, and C-JUN signaling, compared to those exposed to B-cell leukemia. These defects are caused in part by the high expression of CD155 by AML. Overexpressing C-JUN, but not other antigen receptor downstream components, maximally restores anti-tumor function. C-JUN overexpression increases costimulatory molecules and cytokines through reinvigoration of ERK or transcriptional activation, independent of anti-exhaustion. We conduct an open-label, non-randomized, single-arm, phase I trial of C-JUN-overexpressing CAR-T in AML (NCT04835519) with safety and efficacy as primary and secondary endpoints, respectively. Of the four patients treated, one has grade 4 (dose-limiting toxicity) and three have grade 1–2 cytokine release syndrome. Two patients have no detectable bone marrow blasts and one patient has blast reduction after treatment. Thus, overexpressing C-JUN endows CAR-T efficacy in AML.


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Behavioural & social sciences Ecological, evolutionary & environmental sciences For a reference copy of the document with all sections, see nature.com/documents/nr-reporting-summary-flat.pdf All requests for raw and analyzed data will be subject to review by the corresponding authors to determine whether there are any intellectual property or confidentiality considerations.Patient-related data not included in the manuscript may be restricted due to patient confidentiality.We have received IRB approval and have obtained consent to report data on these 4 patients.The clinical trial study protocol is available in the Supplementary Information file.The sequencing data have been deposited in the Genome Sequence Archive database under accession code HRA007312 and HRA004747 at https://ngdc.cncb.ac.cn/gsa-human/ submit/hra/submit.All remaining data can be found in the Article, Supplementary Information, and Source Data files, and from the corresponding author upon reasonable request.Source data are provided with this paper.
Sex: female or male.Consents have been obtained.Gender was not considered in the study design.
We do not use or collect data about ethnicity.
In the preclinical studies, the samples were obtained from healthy donors and patients with diagnosed AML and ALL.
In the clinical trial, to be eligible to participate in this study, an individual must meet all of the following criteria: 1. Candidates with relapse or refractory CD33+ acute myeloid leukemia, who have progressed after treatment with all standard therapies or are intolerant of standard therapy, have limited prognosis with currently available therapies and had no available curative treatment options (such as SCT or chemotherapy); 2. Male or female, aged 1-70 years; 3.No serious allergic constitution; 4. Eastern Cooperative Oncology Group (ECOG) performance status score 0 to 2; 5. Have a life expectancy of at least 60 days based on the investigator's judgment; 6. CD33 positive in bone marrow or cerebrospinal fluid (CSF) by flow cytometry, or CD33 positive in tumor tissues by immunohistochemistry; (CD33 positive criteria: Flow cytometry: Positive: > 80% of tumor cells expressed CD33 and the MFI of CD33 is the same as that in normal myeloid cells; Dim: > 80% of tumor cells expressed CD33, but the MFI of CD33 is lower than that in normal myeloid cells as least as 1log; Partial positive: 20%-80% of tumor cells expressed CD33 and the MFI of CD33 is the same as that in normal myeloid cells.tumor tissue immunohistochemistry: Positive > 30% tumor cells expressed CD33); 7. Provide a signed informed consent before any screening procedure; subjects who voluntarily participate in the study should have the ability to understand and sign the informed consent form and be willing to follow the study visit schedule and relevant study procedure, as specified in the protocol.Candidates aged 19-70 years need to be sufficiently conscious and able to sign the treatment consent form and voluntary consent form.Pediatric patients aged 1-7 years could be recruited after signing an informed consent form by a legal surrogate (Guardian); pediatric patients aged 8-18 years need to be sufficiently conscious and voluntarily sign an informed consent form, and their legal surrogates (guardians) were also required to sign a written informed consent form.
Fresh PBMCs from healthy human blood donors were provided by TianJin Blood Center, and the recruitments of healthy human blood donors were approved by the Ethics Committee of the Institute of Hematology and Blood Diseases Hospital.All the participants signed the Informed Consent Form.
In the clinical trial, participants were recruited by the investigators pursuant to lRB approved methods to reduce the possibility of biased recruiting at Beijing GoBroad Boren Hospital.
All experiments involving human samples were approved by the Ethics Committee of the Institute of Hematology and Blood Diseases Hospital (approval number: NKRDP2021009-EC-2).The Phase I, open-label study (NCT04835519) was conducted at Beijing GoBroad Boren Hospital.The study protocol was approved by the Institutional Review Board (IRB) of Beijing GoBroad Boren Hospital.Written informed consent was obtained from the patients or their legal guardians before enrollment (ethics approval number: 20210331-TY-001K).All clinical investigations were conducted in accordance with the Declaration of Helsinki principles.